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Soncrant C, Mills PD, Neily J, et al. J Patient Saf. 2020;16:41-46.
In this retrospective review of root cause analysis (RCA) reports of select gastrointestinal procedures, researchers identified 27 adverse events 30-month period. Nearly half (48%) of events caused major or catastrophic harm. The most frequently reported adverse events were attributable to human factors (22%), medication errors (22%) or retained items; retained items were associated with the most harm.
Kalisch BJ, McLaughlin M, Dabney BW. Jt Comm J Qual Patient Saf. 2012;38:161-7.
Missed nursing care (failure to perform required patient care elements) is surprisingly common. This qualitative study found that patients were able to reliably identify episodes of missed nursing care and their perceptions correlated with nurses' opinions.
Landro L. Wall Street Journal. March 28, 2011.
This newspaper article discusses how combining best practices in teamwork, simulation, and communication can improve patient safety during obstetric emergencies.
Stein R; USP; United States Pharmacopeia
This article reports on an analysis of data collected by United States Pharmacopeia's voluntary reporting program that found medication errors are seven times more likely to occur during radiological procedures.